Combining mastectomy with reconstruction reduces time, stress

Lori Vajda watches her 13-year-old daughter, Kara Washer, No. 5, a foward for the Barrie Sharks, at her team's hockey practice at Nottawasaga Inn Resort hockey rink in Alliston. Vajda was diagnosed with breast cancer in October 2010 and had bilateral mastectomies and immediate reconstruction in February.

Published on Mon Sep 19 2011

When Lori Vajda woke up in the recovery room of Sunnybrook hospital after a double mastectomy seven months ago, the first thing she did was to look at where her breasts had been.

What she saw were her new breasts.

“Better than they were before,” says the 42-year old registered nurse who lives and works in Barrie. “They looked big again, very full.”

The 14-hour surgery, performed by an oncologic surgeon and a plastic surgeon working in tandem, was a significant medical, esthetic and logistical achievement.

But almost as impressive is the process that preceded the surgery.

Instead of having to arrange separate meetings with each surgeon and then go back and forth with information and decisions, Vajda was able to meet with surgical oncologist Jean-Francois Boileau and plastic surgeon Joan Lipa at the same time at Sunnybrook’s Odette Cancer Centre.

“Having two surgeons in the same room seeing the patient together can expedite and co-ordinate breast cancer care,” explains Lipa. “It can solve a lot of issues and answer a lot of questions, instead of the patient having to bounce back and forth to finalize a plan.”

Before this program was initiated last winter by Drs. Claire Holloway and Laura Snell, a woman diagnosed with breast cancer would find a surgical oncologist and wait for the appointment, and then do the same with a plastic surgeon and try to co-ordinate it all.

“And then maybe the patient has other questions: Do we do nipple sparing or not? What about the other breast, if the cancer is on one side?,” says Lipa. “There was a lot of back and forth before the final plan. This program cuts down on some of that co-ordination time and waiting.”

Also amazing to Vajda is that her meeting with the surgeons on Jan. 4 took place on time. “It was scheduled for 2 p.m.,” she recalls, “and at five minutes to 2, I was brought into the room and they were both there.”

“I would love to say we could be on time for everybody,” says Lipa. “These women are going through so much and time spent waiting adds to stress.”

The concept of an immediate breast reconstruction clinic, along with patient conferences, is unique in the Toronto area, says Lipa.

And the benefits for patients are compelling, says Karen Fergus, psychologist in the patient and family support program at Odette.

Just knowing that both surgeons, even though they have different functions, are working as a team is very important for the patient, she says.

Beyond that, being an active participant is “both reassuring and empowering” to women considering immediate reconstruction, she says.

“Having both a presence and a voice in these discussions is a big step toward providing a greater sense of control over what is essentially a very difficult loss,” says Fergus, noting the “significant impacts on a woman’s body image, self-esteem, and identity.”

Even though Vajda, as an experienced R.N., had more medical knowledge than most mastectomy patients, she found the meeting with her surgical team to be invaluable.

Given a diagnosis of Grade 3/3 ductal carcinoma in situ (DCIS) — “the worst of the best kind of breast cancer,” explains Vajda — she was originally told she had several options: lumpectomy, mastectomy with implant, or reconstruction using her own abdominal tissue, with or without muscle-sparing — the so-called TRAM or DIEP free-flap surgeries.

After a lumpectomy revealed that the margins of cancerous clusters were not clear, and an MRI revealed a suspicious spot in her other breast (which turned out to be insignificant), Vajda decided she didn’t want to worry about the cancer returning.

She also knew that the history of ovarian cancer in her family increased her risk of a recurrence.

“I didn’t want to play the waiting game,” she says.

So she decided to go ahead with a double mastectomy with immediate reconstruction.

At the meeting with Lipa and Boileau, they decided to do a muscle-sparing flap reconstruction using abdominal tissue, which also resulted in a flatter tummy — a fringe benefit.

“They didn’t treat me like a nurse,” Vajda recalls. “They laid it all out for me. It was such good pre-op teaching that I knew exactly what to expect. I was told I’d have a lot of pain and it was a painful recovery.”

Now, Vajda can look back, confident that she and her surgeons together made the right decision about her treatment.

She can also look down and feel good about what she sees. “I’m happier with my breasts now than before my surgery,” she says. “The scarring is very minimal.”

She’s especially relieved because, she admits, just before the surgery, she thought, “These are some of the best things about me and now I’m going to lose them.”

“Even before my surgery, I was happy with my breasts. I was a C cup before and I’m a C cup after. But now, if I don’t want to, I don’t have to wear a bra. I’m 42 and I’m defying gravity.”

The greatest benefit, of course, is not that she was able to wear a tankini and show off a tanned tummy all summer.

The greatest relief and benefit is knowing that the “risk of recurrence is very low, less than 2 per cent, because the breast tissue is gone, out of me. In my mind, it’s over.”

Do you qualify?

Women getting mastectomies may be candidates for immediate breast reconstruction if they are otherwise in good health with no major illnesses — usually non-smokers and not obese.

Both smoking and obesity increase the risks of doing an immediate breast reconstruction, says Sunnybrook plastic surgeon Joan Lipa. “We don’t want complications that are going to delay other treatments they may need.”

Also, she advises, women who are not going to have radiation treatments are the best candidates for immediate reconstruction.

If a patient is deemed to be a good fit for the program, she will be booked into the Odette clinic and scheduled for a co-ordinated meeting with the surgical oncologist and the plastic surgeon.

“Things start to get co-ordinated right away,” says Lipa. “A lot of the consultations take a long time — figuring out what that woman wants and what might be right for her.”

She and her colleagues offer “the full spectrum” of breast reconstruction, including the DIEP flap, which spares the abdominal muscle and is not offered at community hospitals.

Although breast cancer patients are often well-informed, either through the Internet or peer support, Lipa says some don’t think to ask about reconstruction right away. Plastic surgeons are trying to raise awareness with a Canada-wide National Breast Reconstruction Day on Oct. 19. For more information, go to bra-day.com.

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